Patient Safety measures

(HAC 01) Count of Hospital-Acquired Condition - Surgical Events: Foreign Object Retained after Surgery.

Includes Secondary Diagnosis Codes not present on admission (POA = N or U): 998.4, 998.7, T81500A, T81501A, T81502A, T81503A, T81504A, T81505A, T81506A, T81507A, T81508A, T81509A, T81510A, T81511A, T81512A, T81513A, T81514A, T81515A, T81516A, T81517A, T81518A, T81519A, T81520A, T81521A, T81522A, T81523A, T81524A, T81525A, T81526A, T81527A, T81528A, T81529A, T81530A, T81531A, T81532A, T81533A, T81534A, T81535A, T81536A, T81537A, T81538A, T81539A, T81590A, T81591A, T81592A, T81593A, T81594A, T81595A, T81596A, T81597A, T81598A, T81599A, T8160XA, T8161XA, and T8169XA

(HAC 02) Count of Hospital-Acquired Condition - Medical Events: Air Embolism.

Includes Secondary Diagnosis Codes not present on admission (POA = N or U): 999.1 and T800XXA

(HAC 03) Count of Hospital-Acquired Condition - Medical Events: Blood Incompatibility.

Includes Secondary Diagnosis Codes not present on admission (POA = N or U): 999.60, 999.61, 999.62, 999.63, 999.69, T8030XA, T80310A, T80311A, T80319A, and T8039XA

(HAC 04) Count of Hospital-Acquired Condition - Medical Events: Pressure Ulcer- Stage III and IV.

Includes Secondary Diagnosis Codes not present on admission (POA = N or U): 707.23, 707.24, L89003, L89004, L89013, L89014, L89023, L89024, L89103, L89104, L89113, L89114, L89123, L89124, L89133, L89134, L89143, L89144, L89153, L89154, L89203, L89204, L89213, L89214, L89223, L89224, L89303, L89304, L89313, L89314, L89323, L89324, L8943, L8944, L89503, L89504, L89513, L89514, L89523, L89524, L89603, L89604, L89613, L89614, L89623, L89624, L89813, L89814, L89893, L89894, L8993, and L8994

(HAC 05) Count of Hospital-Acquired Condition - Medical Events: Falls and Trauma.

Includes Secondary Diagnosis Codes not present on admission (POA = N or U): 800-829, 830-839, 850-854, 925-929, 940-949, 991-994 and 3,726 ICD-10 Diagnosis Codes

(HAC 06) Count of Hospital-Acquired Condition - Medical Events: Catheter-associated Urinary Tract Infection.

Includes Secondary Diagnosis Codes not present on admission (POA = N or U): 996.64, T83511A, and T83518A

(HAC 07) Count of Hospital-Acquired Condition - Medical Events: - Vascular Catheter-Associated Infection.

Includes Secondary Diagnosis Codes not present on admission (POA = N or U): 999.31, T80211A, T80212A, T80218A, and T80219A

(HAC 08) Count of Hospital-Acquired Condition - Surgical Events: - Mediastinitis after CABG.

For encounters with one of the following procedure codes: 36.10-36.19, 0210083, 0210088, 0210089, 021008C, 021008F, 021008W, 0210093, 0210098, 0210099, 021009C, 021009F, 021009W, 02100A3, 02100A8, 02100A9, 02100AC, 02100AF, 02100AW, 02100J3, 02100J8, 02100J9, 02100JC, 02100JF, 02100JW, 02100K3, 02100K8, 02100K9, 02100KC, 02100KF, 02100KW, 02100Z3, 02100Z8, 02100Z9, 02100ZC, 02100ZF, 0210483, 0210488, 0210489, 021048C, 021048F, 021048W, 0210493, 0210498, 0210499, 021049C, 021049F, 021049W, 02104A3, 02104A8, 02104A9, 02104AC, 02104AF, 02104AW, 02104J3, 02104J8, 02104J9, 02104JC, 02104JF, 02104JW, 02104K3, 02104K8, 02104K9, 02104KC, 02104KF, 02104KW, 02104Z3, 02104Z8, 02104Z9, 02104ZC, 02104ZF, 0211083, 0211088, 0211089, 021108C, 021108F, 021108W, 0211093, 0211098, 0211099, 021109C, 021109F, 021109W, 02110A3, 02110A8, 02110A9, 02110AC, 02110AF, 02110AW, 02110J3, 02110J8, 02110J9, 02110JC, 02110JF, 02110JW, 02110K3, 02110K8, 02110K9, 02110KC, 02110KF, 02110KW, 02110Z3, 02110Z8, 02110Z9, 02110ZC, 02110ZF, 0211483, 0211488, 0211489, 021148C, 021148F, 021148W, 0211493, 0211498, 0211499, 021149C, 021149F, 021149W, 02114A3, 02114A8, 02114A9, 02114AC, 02114AF, 02114AW, 02114J3, 02114J8, 02114J9, 02114JC, 02114JF, 02114JW, 02114K3, 02114K8, 02114K9, 02114KC, 02114KF, 02114KW, 02114Z3, 02114Z8, 02114Z9, 02114ZC, 02114ZF, 0212083, 0212088, 0212089, 021208C, 021208F, 021208W, 0212093, 0212098, 0212099, 021209C, 021209F, 021209W, 02120A3, 02120A8, 02120A9, 02120AC, 02120AF, 02120AW, 02120J3, 02120J8, 02120J9, 02120JC, 02120JF, 02120JW, 02120K3, 02120K8, 02120K9, 02120KC, 02120KF, 02120KW, 02120Z3, 02120Z8, 02120Z9, 02120ZC, 02120ZF, 0212483, 0212488, 0212489, 021248C, 021248F, 021248W, 0212493, 0212498, 0212499, 021249C, 021249F, 021249W, 02124A3, 02124A8, 02124A9, 02124AC, 02124AF, 02124AW, 02124J3, 02124J8, 02124J9, 02124JC, 02124JF, 02124JW, 02124K3, 02124K8, 02124K9, 02124KC, 02124KF, 02124KW, 02124Z3, 02124Z8, 02124Z9, 02124ZC, 02124ZF, 0213083, 0213088, 0213089, 021308C, 021308F, 021308W, 0213093, 0213098, 0213099, 021309C, 021309F, 021309W, 02130A3, 02130A8, 02130A9, 02130AC, 02130AF, 02130AW, 02130J3, 02130J8, 02130J9, 02130JC, 02130JF, 02130JW, 02130K3, 02130K8, 02130K9, 02130KC, 02130KF, 02130KW, 02130Z3, 02130Z8, 02130Z9, 02130ZC, 02130ZF, 0213483, 0213488, 0213489, 021348C, 021348F, 021348W, 0213493, 0213498, 0213499, 021349C, 021349F, 021349W, 02134A3, 02134A8, 02134A9, 02134AC, 02134AF, 02134AW, 02134J3, 02134J8, 02134J9, 02134JC, 02134JF, 02134JW, 02134K3, 02134K8, 02134K9, 02134KC, 02134KF, 02134KW, 02134Z3, 02134Z8, 02134Z9, 02134ZC, or 02134ZF

Includes Secondary Diagnosis Codes not present on admission (POA = N or U): 519.2, J9851, and J9859

(HAC 09) Hospital-Acquired Condition - Medical Events: Poor Glycemic Control.

Includes Secondary Diagnosis Codes not present on admission (POA = N or U): E0800, E0801, E0810, E0900, E0901, E0910, E1010, E1100, E1101, E1300, E1301, E1310, and E15

Count of Hospital-Acquired Condition - Medical Events: Poor Glycemic Control - Diabetic Ketoacidosis (a subset of HAC 09)

Includes Secondary Diagnosis Codes not present on admission (POA = N or U): E0910, E1010, and E1310

Hospital-Acquired Condition - Medical Events: Poor Glycemic Control - Hypoglycemic Coma (a subset of HAC 09)

Includes Secondary Diagnosis Codes not present on admission (POA = N or U): E0801, E0901, E1101, E1301, and E15

Hospital-Acquired Condition - Medical Events: Poor Glycemic Control - Nonketotic Hyperosmolar Coma (a subset of HAC 09)

Includes Secondary Diagnosis Codes not present on admission (POA = N or U): E0801, E0901, E1101, and E1301

Hospital-Acquired Condition - Medical Events: Poor Glycemic Control - Secondary Diabetes with Hyperosmolarity (a subset of HAC 09)

Includes Secondary Diagnosis Codes not present on admission (POA = N or U): E0800, E0801, E0900, E0901, E1100, E1101, E1300, and E1301

Hospital-Acquired Condition - Medical Events: Poor Glycemic Control - Secondary Diabetes with Ketoacidosis (a subset of HAC 09)

Includes Secondary Diagnosis Codes not present on admission (POA = N or U): E0810, E0910, E1010, and E1310

(HAC 10) Count of Hospital-Acquired Condition - Surgical Events: - Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE) After Knee or Hip Replacement.

For encounters with one of the following Procedure Codes: 00.85-00.87, 81.51-81.52, 81.54, 0SR9019, 0SR901A, 0SR901Z, 0SR9029, 0SR902A, 0SR902Z, 0SR9039, 0SR903A, 0SR903Z, 0SR9049, 0SR904A, 0SR904Z, 0SR9069, 0SR906A, 0SR906Z, 0SR907Z, 0SR90J9, 0SR90JA, 0SR90JZ, 0SR90KZ, 0SRA009, 0SRA00A, 0SRA00Z, 0SRA019, 0SRA01A, 0SRA01Z, 0SRA039, 0SRA03A, 0SRA03Z, 0SRA07Z, 0SRA0J9, 0SRA0JA, 0SRA0JZ, 0SRA0KZ, 0SRB019, 0SRB01A, 0SRB01Z, 0SRB029, 0SRB02A, 0SRB02Z, 0SRB039, 0SRB03A, 0SRB03Z, 0SRB049, 0SRB04A, 0SRB04Z, 0SRB069, 0SRB06A, 0SRB06Z, 0SRB07Z, 0SRB0J9, 0SRB0JA, 0SRB0JZ, 0SRB0KZ, 0SRC069, 0SRC06A, 0SRC06Z, 0SRC07Z, 0SRC0J9, 0SRC0JA, 0SRC0JZ, 0SRC0KZ, 0SRC0L9, 0SRC0LA, 0SRC0LZ, 0SRD069, 0SRD06A, 0SRD06Z, 0SRD07Z, 0SRD0J9, 0SRD0JA, 0SRD0JZ, 0SRD0KZ, 0SRD0L9, 0SRD0LA, 0SRD0LZ, 0SRE009, 0SRE00A, 0SRE00Z, 0SRE019, 0SRE01A, 0SRE01Z, 0SRE039, 0SRE03A, 0SRE03Z, 0SRE07Z, 0SRE0J9, 0SRE0JA, 0SRE0JZ, 0SRE0KZ, 0SRR019, 0SRR01A, 0SRR01Z, 0SRR039, 0SRR03A, 0SRR03Z, 0SRR07Z, 0SRR0J9, 0SRR0JA, 0SRR0JZ, 0SRR0KZ, 0SRS019, 0SRS01A, 0SRS01Z, 0SRS039, 0SRS03A, 0SRS03Z, 0SRS07Z, 0SRS0J9, 0SRS0JA, 0SRS0JZ, 0SRS0KZ, 0SRT07Z, 0SRT0J9, 0SRT0JA, 0SRT0JZ, 0SRT0KZ, 0SRU07Z, 0SRU0J9, 0SRU0JA, 0SRU0JZ, 0SRU0KZ, 0SRV07Z, 0SRV0J9, 0SRV0JA, 0SRV0JZ, 0SRV0KZ, 0SRW07Z, 0SRW0J9, 0SRW0JA, 0SRW0JZ, 0SRW0KZ, 0SU90BZ, 0SUA0BZ, 0SUB0BZ, 0SUE0BZ, 0SUR0BZ, or 0SUS0BZ

Includes Secondary Diagnosis Codes not present on admission (POA = N or U): 415.11, 415.1, 415.19, 453.40-453.42, I2602, I2609, I2692, I2699, I82401, I82402, I82403, I82409, I82411, I82412, I82413, I82419, I82421, I82422, I82423, I82429, I82431, I82432, I82433, I82439, I82441, I82442, I82443, I82449, I82491, I82492, I82493, I82499, I824Y1, I824Y2, I824Y3, I824Y9, I824Z1, I824Z2, I824Z3, and I824Z9

Count of Hospital-Acquired Condition - Surgical Events: - DVT/PE after THR (a subset of HAC 10)

For encounters with one of the following Procedure Codes: 00.85-00.87, 81.51-81.52, 81.54, 0SR9019, 0SR901A, 0SR901Z, 0SR9029, 0SR902A, 0SR902Z, 0SR9039, 0SR903A, 0SR903Z, 0SR9049, 0SR904A, 0SR904Z, 0SR9069, 0SR906A, 0SR906Z, 0SR907Z, 0SR90J9, 0SR90JA, 0SR90JZ, 0SR90KZ, 0SRA009, 0SRA00A, 0SRA00Z, 0SRA019, 0SRA01A, 0SRA01Z, 0SRA039, 0SRA03A, 0SRA03Z, 0SRA07Z, 0SRA0J9, 0SRA0JA, 0SRA0JZ, 0SRA0KZ, 0SRB019, 0SRB01A, 0SRB01Z, 0SRB029, 0SRB02A, 0SRB02Z, 0SRB039, 0SRB03A, 0SRB03Z, 0SRB049, 0SRB04A, 0SRB04Z, 0SRB069, 0SRB06A, 0SRB06Z, 0SRB07Z, 0SRB0J9, 0SRB0JA, 0SRB0JZ, 0SRB0KZ, 0SRE009, 0SRE00A, 0SRE00Z, 0SRE019, 0SRE01A, 0SRE01Z, 0SRE039, 0SRE03A, 0SRE03Z, 0SRE07Z, 0SRE0J9, 0SRE0JA, 0SRE0JZ, 0SRE0KZ, 0SRR019, 0SRR01A, 0SRR01Z, 0SRR039, 0SRR03A, 0SRR03Z, 0SRR07Z, 0SRR0J9, 0SRR0JA, 0SRR0JZ, 0SRR0KZ, 0SRS019, 0SRS01A, 0SRS01Z, 0SRS039, 0SRS03A, 0SRS03Z, 0SRS07Z, 0SRS0J9, 0SRS0JA, 0SRS0JZ, 0SRS0KZ, 0SU90BZ, 0SUA0BZ, 0SUB0BZ, 0SUE0BZ, 0SUR0BZ, or 0SUS0BZ

Includes Secondary Diagnosis Codes not present on admission (POA = N or U): 415.11, 415.1, 415.19, 453.40-453.42, I2602, I2609, I2692, I2699, I82401, I82402, I82403, I82409, I82411, I82412, I82413, I82419, I82421, I82422, I82423, I82429, I82431, I82432, I82433, I82439, I82441, I82442, I82443, I82449, I82491, I82492, I82493, I82499, I824Y1, I824Y2, I824Y3, I824Y9, I824Z1, I824Z2, I824Z3, and I824Z9

Count of Hospital-Acquired Condition - Surgical Events: - DVT/PE after TKR (a subset of HAC 10)

For encounters with one of the following Procedure Codes: 00.85-00.87, 81.51-81.52, 81.54, 0SRC069, 0SRC06A, 0SRC06Z, 0SRC07Z, 0SRC0J9, 0SRC0JA, 0SRC0JZ, 0SRC0KZ, 0SRC0L9, 0SRC0LA, 0SRC0LZ, 0SRD069, 0SRD06A, 0SRD06Z, 0SRD07Z, 0SRD0J9, 0SRD0JA, 0SRD0JZ, 0SRD0KZ, 0SRD0L9, 0SRD0LA, 0SRD0LZ 0SRT07Z, 0SRT0J9, 0SRT0JA, 0SRT0JZ, 0SRT0KZ, 0SRU07Z, 0SRU0J9, 0SRU0JA, 0SRU0JZ, 0SRU0KZ, 0SRV07Z, 0SRV0J9, 0SRV0JA, 0SRV0JZ, 0SRV0KZ, 0SRW07Z, 0SRW0J9, 0SRW0JA, 0SRW0JZ, or 0SRW0KZ

Includes Secondary Diagnosis Codes not present on admission (POA = N or U): 415.11, 415.1, 415.19, 453.40-453.42, I2602, I2609, I2692, I2699, I82401, I82402, I82403, I82409, I82411, I82412, I82413, I82419, I82421, I82422, I82423, I82429, I82431, I82432, I82433, I82439, I82441, I82442, I82443, I82449, I82491, I82492, I82493, I82499, I824Y1, I824Y2, I824Y3, I824Y9, I824Z1, I824Z2, I824Z3, and I824Z9

(HAC 11) Hospital-Acquired Condition - Surgical Events: - Surgical Site Infection - After Bariatric Surgery for Obesity

For encounters with a Principal Diagnosis Code of E6601 and a Procedure Code of: 0D16079, 0D1607A, 0D1607B, 0D1607L, 0D160J9, 0D160JA, 0D160JB, 0D160JL, 0D160K9, 0D160KA, 0D160KB, 0D160KL, 0D160Z9, 0D160ZA, 0D160ZB, 0D160ZL, 0D16479, 0D1647A, 0D1647B, 0D1647L, 0D164J9, 0D164JA, 0D164JB, 0D164JL, 0D164K9, 0D164KA, 0D164KB, 0D164KL, 0D164Z9, 0D164ZA, 0D164ZB, 0D164ZL, 0D16879, 0D1687A, 0D1687B, 0D1687L, 0D168J9, 0D168JA, 0D168JB, 0D168JL, 0D168K9, 0D168KA, 0D168KB, 0D168KL, 0D168Z9, 0D168ZA, 0D168ZB, 0D168ZL, or 0DV64CZ

Includes Secondary Diagnosis Codes not present on admission (POA = N or U): K6811, K9501, K9581, and T814XXA

(HAC 12) Hospital-Acquired Condition - Surgical Events: - Surgical Site Infection - After Certain Orthopedic Surgeries

For encounters with a Procedure Code for certain orthopedic procedure of the spine, shoulder, or elbow (includes 744 ICD-10 Procedure Codes)

Includes Secondary Diagnosis Codes not present on admission (POA = N or U): K6811, T814XXA, T8460XA, T84610A, T84611A, T84612A, T84613A, T84614A, T84615A, T84619A, T8463XA, T8469XA, or T847XXA

(HAC 13) Hospital-Acquired Condition - Surgical Events: Surgical Site Infection - After Cardiac Implantable Electronic Device (CIED)

For encounters with a procedure code of: 02H43JZ, 02H43KZ, 02H43MZ, 02H63JZ, 02H63MZ, 02H73JZ, 02H73MZ, 02HK3JZ, 02HL3JZ, 02HN0JZ, 02HN0MZ, 02HN3JZ, 02HN3MZ, 02HN4JZ, 02HN4MZ, 02PA0MZ, 02PA3MZ, 02PA4MZ, 02PAXMZ, 02WA0MZ, 02WA3MZ, 02WA4MZ, 0JH604Z, 0JH605Z, 0JH606Z, 0JH607Z, 0JH608Z, 0JH609Z, 0JH60PZ, 0JH634Z, 0JH635Z, 0JH636Z, 0JH637Z, 0JH638Z, 0JH639Z, 0JH63PZ, 0JH804Z, 0JH805Z, 0JH806Z, 0JH807Z, 0JH808Z, 0JH809Z, 0JH80PZ, 0JH834Z, 0JH835Z, 0JH836Z, 0JH837Z, 0JH838Z, 0JH839Z, 0JH83PZ, 0JPT0PZ, 0JPT3PZ, 0JWT0PZ, 0JWT3PZ

Includes Secondary Diagnosis Codes not present on admission (POA = N or U): K6811, T814XXA, T826XXA, and T827XXA

(HAC 14) Count of Hospital-Acquired Condition - Iatrogenic Pneumothorax with Venous Catheterization.

For encounters with one of the following procedure codes: 02H633Z, 02HK33Z, 02HS33Z, 02HS43Z, 02HT33Z, 02HT43Z, 02HV33Z, 02HV43Z, 05H033Z, 05H043Z, 05H133Z, 05H143Z, 05H333Z, 05H343Z, 05H433Z, 05H443Z, 05H533Z, 05H543Z, 05H633Z, 05H643Z, 05HM33Z, 05HN33Z, 05HP33Z, 05HQ33Z, or 0JH63XZ

Includes Secondary Diagnosis Code not present on admission (POA = N or U): J95811

Total Hospital-Acquired Conditions (HAC) is the number of Total Surgical HACs and Total Medical HACs: Foreign Object Retained after Surgery (HAC 01), Air Embolism (HAC 02), Blood Incompatibility (HAC 03), Pressure Ulcer- Stage III and IV (HAC 04), Falls and Trauma (HAC 05), Catheter-associated UTI (HAC 06), Vascular Catheter-Associated Infection (HAC 07), Mediastinitis after CABG (HAC 08), Poor Glycemic Control (HAC 09), Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE) After Knee or Hip Replacement (HAC 10), Surgical Site Infection - After Bariatric Surgery for Obesity (HAC 11), Surgical Site Infection - After Certain Orthopedic Surgeries (HAC 12), Surgical Site Infection - After CIED (HAC 13), Iatrogenic Pneumothorax with Venous Catheterization (HAC 14)

See definitions above.

Patient had one of the following diagnosis codes in any position, not Present on Admission (POA):

D47Z1, D7801, D7802, D7811, D7812, D7821, D7822, D7881, D7889, E3601, E3602, E3611, E3612, E83111, E8771, E889, E890, E891, E892, E893, E8940, E8941, E895, E896, E89810, E89811, E8989, G038, G0402, G970, G971, G9731, G9732, G9748, G9749, G9751, G9752, G9781, G9782, H59111, H59112, H59113, H59119, H59121, H59122, H59123, H59129, H59211, H59212, H59213, H59219, H59221, H59222, H59223, H59229, H59311, H59312, H59313, H59319, H59321, H59322, H59323, H59329, H5988, H5989, H9521, H9522, H9531, H9532, H9541, H9542, H95811, H95812, H95813, H95819, H9588, H9589, I230, I231, I232, I233, I234, I235, I236, I238, I970, I972, I973, I97410, I97411, I97418, I9742, I9751, I9752, I97610, I97618, I97710, I97711, I97790, I97791, I9788, I9789, I998, J951, J952, J953, J955, J9561, J9562, J9571, J9572, J95811, J95812, J95821, J95822, J95830, J95831, J95850, J95859, J9588, J9589, J989, K910, K911, K912, K913, K915, K9161, K9162, K9171, K9172, K9181, K9182, K91840, K91841, K91858, K9189, K929, K9400, K9401, K9402, K9403, K9409, K9410, K9411, K9412, K9413, K9419, K9420, K9421, K9422, K9423, K9430, K9431, K9432, K9433, K9439, K9581, L7601, L7602, L7611, L7612, L7621, L7622, L7681, L7682, M2759, M961, M962, M963, M965, M96810, M96811, M96820, M96821, M96830, M96831, M9689, N509, N650, N651, N949, N980, N981, N982, N983, N988, N989, N992, N993, N99510, N99511, N99512, N99518, N99520, N99521, N99522, N99528, N99530, N99531, N99532, N99538, N9961, N9962, N9971, N9972, N99821, N9989, O080, O081, O082, O083, O084, O086, O087, O0881, O0882, O0883, O0889, O089, O29191, O29192, O29193, O29199, O29291, O29292, O29293, O29299, O295X1, O295X2, O295X3, O295X9, O2960, O2961, O2962, O2963, O6989X0, O6989X1, O6989X2, O6989X3, O6989X4, O6989X5, O6989X9, O699XX0, O699XX1, O699XX2, O699XX3, O699XX4, O699XX5, O699XX9, O741, O742, O743, O745, O746, O749, O754, O7589, O759, O860, O8909, O891, O892, O894, O895, O900, O901, O902, R5084, T8119XA, T8119XD, T8119XS, T814XXA, T814XXD, T814XXS, T81710A, T81710D, 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T84010S, T84011A, T84011D, T84011S, T84012A, T84012D, T84012S, T84013A, T84013D, T84013S, T84018A, T84018D, T84018S, T84019A, T84019D, T84019S, T84020A, T84020D, T84020S, T84021A, T84021D, T84021S, T84022A, T84022D, T84022S, T84023A, T84023D, T84023S, T84028A, T84028D, T84028S, T84029A, T84029D, T84029S, T84030A, T84030D, T84030S, T84031A, T84031D, T84031S, T84032A, T84032D, T84032S, T84033A, T84033D, T84033S, T84038A, T84038D, T84038S, T84039A, T84039D, T84039S, T84050A, T84050D, T84050S, T84051A, T84051D, T84051S, T84052A, T84052D, T84052S, T84053A, T84053D, T84053S, T84058A, T84058D, T84058S, T84059A, T84059D, T84059S, T84060A, T84060D, T84060S, T84061A, T84061D, T84061S, T84062A, T84062D, T84062S, T84063A, T84063D, T84063S, T84068A, T84068D, T84068S, T84069A, T84069D, T84069S, T84090A, T84090D, T84090S, T84091A, T84091D, T84091S, T84092A, T84092D, T84092S, T84093A, T84093D, T84093S, T84098A, T84098D, T84098S, T84099A, T84099D, T84099S, T84110A, T84110D, T84110S, T84111A, T84111D, 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Y625, Y626, Y628, Y629, Y630, Y631, Y632, Y633, Y634, Y635, Y636, Y638, Y639, Y640, Y641, Y648, Y649, Y650, Y651, Y652, Y653, Y654, Y6551, Y6552, Y6553, Y658, Y66, Y69, Y700, Y701, Y702, Y703, Y708, Y710, Y711, Y712, Y713, Y718, Y720, Y721, Y722, Y723, Y728, Y730, Y731, Y732, Y733, Y738, Y740, Y741, Y742, Y743, Y748, Y750, Y751, Y752, Y753, Y758, Y760, Y761, Y762, Y763, Y768, Y770, Y771, Y772, Y773, Y778, Y780, Y781, Y782, Y783, Y788, Y790, Y791, Y792, Y793, Y798, Y800, Y801, Y802, Y803, Y808, Y810, Y811, Y812, Y813, Y818, Y828, Y829, Y830, Y831, Y832, Y833, Y834, Y835, Y836, Y838, Y839, Y840, Y841, Y842, Y843, Y844, Y845, Y846, Y847, Y848, Y849, D7831, D7832, D7833, D7834, E89822, E89823, G9761, G9762, G9763, G9764, H59361, H59362, H59363, H59369, H9551, H9552, H9553, H9554, I97620, I97622, I97640, I97641, J95860, J95861, J95862, J95863, K91872, K91873, L7631, L7632, L7633, M96840, M96841, M96842, M96843, N99523, N99524, N99533, N99534, N99842, N99843, T83011A, T83011D, T83011S, T83021A, T83021D, T83021S, T83031A, T83031D, T83031S, T83091A, T83091D, T83091S, T83113A, T83113D, T83113S, T83123A, T83123D, T83123S, T83193A, T83193D, T83193S, T8324XA, T8324XD, T8324XS, T8325XA, T8325XD, T8325XS, T83510A, T83510D, T83510S, T83511A, T83511D, T83511S, T83518A, T83518D, T83518S, T83591A, T83591D, T83591S, T83593A, T83593D, T83593S, T83598A, T83598D, T83598S, T8361XA, T8361XD, T8361XS, T8369XA, T8369XD, T8369XS, T83712A, T83712D, T83712S, T83713A, T83713D, T83713S, T83714A, T83714D, T83714S, T83722A, T83722D, T83722S, T83723A, T83723D, T83723S, T83724A, T83724D, T83724S, T8379XA, T8379XD, T8379XS, T85113A, T85113D, T85113S, T85123A, T85123D, T85123S, T85193A, T85193D, T85193S, T85615A, T85615D, T85615S, T85625A, T85625D, T85625S, T85635A, T85635D, T85635S, T85695A, T85695D, T85695S, T85730A, T85730D, T85730S, T85731A, T85731D, T85731S, T85732A, T85732D, T85732S, T85733A, T85733D, T85733S, T85735A, T85735D, T85735S, T85738A, T85738D, T85738S, T85810A, T85810D, T85810S, T85818A, T85818D, T85818S, T85820A, T85820D, T85820S, T85828A, T85828D, T85828S, T85830A, T85830D, T85830S, T85838A, T85838D, T85838S, T85840A, T85840D, T85840S, T85848A, T85848D, T85848S, T85850A, T85850D, T85850S, T85858A, T85858D, T85858S, T85860A, T85860D, T85860S, T85868A, T85868D, T85868S, T85890A, T85890D, T85890S, T85898A, T85898D, T85898S, T8853XA, T8853XD, T8853XS

Harm Rate

The Harm Rate is the rate at which certain CMS Hospital Acquired Conditions and AHRQ Patient Safety Indicators occur among all patients. The measured events include Post-op DVT/PE (AHRQ PSI 12), Post-op sepsis (AHRQ PSI 13), Pressure Ulcer (stage 3-4) (CMS HAC), Central line infection (CMS HAC), Falls and Trauma (CMS HAC). A patient experiencing any one of the events listed is flagged as having experienced a harmful event. The rate is calculated as the sum of patients experiencing a harmful event divided by the total number of patients.

Low

Post-Operative Infection - O/E Ratio

Observed number of cases with a post-operative infection, divided by the benchmark (expected) value.

Post-operative infection diagnosis codes: 99660-99669, 9985, 9993, T8579XA, T826XXA, T827XXA, T8351XA, T8359XA, T836XXA, T8450XA, T8460XA, T847XXA, T8571XA, K6811, T814XXA, T80219A, T8029XA, T880XXA

Low

Post-Operative Infection - Rate

Number of Cases with a diagnosis code for a post-operative infection divided by the number of Surgical Cases

Post-operative infection diagnosis codes: 99660-99669, 9985, 9993, T8579XA, T826XXA, T827XXA, T8351XA, T8359XA, T836XXA, T8450XA, T8460XA, T847XXA, T8571XA, K6811, T814XXA, T80219A, T8029XA, T880XXA

Low

Respiratory Complications

Rate of respiratory complications (based on flag in client data)

Low

Survival Rate

Total live discharges divided by total discharges

High

Survival without Palliative Rate

Total live discharges divided by total discharges of patients without a diagnosis code for palliative care

High

AMI within 7 days of index admission

The encounter is flagged for this event if either of the following conditions are present:

-A secondary diagnosis code for AMI, not POA

-A principal diagnosis code for AMI on a subsequent encounter with the admit date within 7 days of the admit date of the initial encounter

Low

Pneumonia within 7 days of index admission

The encounter is flagged for this event if either of the following conditions are present:

-A secondary diagnosis code for Pneumonia, not POA

-A principal diagnosis code for Pneumonia on a subsequent encounter with the admit date within 7 days of the admit date of the initial encounter

Low

Sepsis within 7 days of index admission

The encounter is flagged for this event if either of the following conditions are present:

-A diagnosis code for sepsis, septicemia, or septic shock, not POA

-A diagnosis code for sepsis, septicemia, or septic shock on a subsequent encounter with an admit date within 7 days of the admit date of the initial encounter

Low

Surgical site bleed within 30 days of index admission

The encounter is flagged for this event if either of the following conditions are present:

-A diagnosis code for Surgical Site Bleeding, not POA

-A diagnosis code for Surgical Site Bleeding on a subsequent encounter with an admit date within 30 days of the admit date of the initial encounter

Low

Pulmonary embolism within 30 days of index admission

The encounter is flagged for this event if either of the following conditions are present:

-A diagnosis code for Pulmonary Embolism, not POA

-A diagnosis code for Pulmonary Embolism on a subsequent encounter with an admit date within 30 days of the admit date of the initial encounter.

Low

Mortality within 30 days of admission

The encounter is flagged for this event if either of the following conditions are present:

-The discharge disposition indicates the patient expired

-The discharge disposition indicates expired on a subsequent encounter with a discharge date within 30 days of the admit date of the initial encounter

Low

Mechanical complications within 90 days of index admission

The encounter is flagged for this event if either of the following conditions are present:

-A diagnosis code for Mechanical Complications, not POA

-A diagnosis code for Mechanical Complications on a subsequent encounter with an admit date within 90 days of the admit date of the initial encounter

Low

Periprosthetic joint/wound infection within 90 days of index admission

The encounter is flagged for this event if either of the following conditions are present:

-A diagnosis code for Periprosthetic Joint or Wound Infection, not POA

-A diagnosis code for Periprosthetic Joint or Wound Infection on a subsequent encounter with an admit date within 90 days of the admit date of the initial encounter

Low

Unexplained Cardiac Arrest

Encounter has a diagnosis code of I462, I468 or I469, not POA

Low

Dysglycemia

Encounter has a diagnosis code of E15, not POA

Low

Postoperative Atrial Fibrillation

Encounter has a major procedure (HCUP Procedure Class of 3 or 4) and a diagnosis code of I480, I481, I482, I4891, I4991, or I4901, not POA

Low

Postoperative Respiratory Failure

Encounter has a major procedure (HCUP Procedure Class of 3 or 4) and a diagnosis code of J95821, J9600, or J9601, not POA

Low

Myocardial Rupture

Encounter has a diagnosis code of I23.3, not POA

Low

Pleural Effusion

Encounter has a diagnosis code of J90, J918, J940, or J942, not POA

Low

Congestive Heart Failure

Encounter has a diagnosis code of I5020, I5021, I5022, I5023, I5030, I5031, I5032, I5033, I5040, I5041, I5042, or I5043, not POA

Low

Stroke/cerebrovascular accident

Encounter has a diagnosis code of I6300, I63011, I63012, I63019, I6302, I63031, I63032, I63039, I6309, I6310, I63111, I63112, I63119, I6312, I63131, I63132, I63139, I6319, I6320, I63211, I63212, I63219, I6322, I63231, I63232, I63239, I6329, I6330, I63311, I63312, I63319, I63321, I63322, I63329, I63331, I63332, I63339, I63341, I63342, I63349, I6339, I6340, I63411, I63412, I63419, I63421, I63422, I63429, I63431, I63432, I63439, I63441, I63442, I63449, I6349, I6350, I63511, I63512, I63519, I63521, I63522, I63529, I63531, I63532, I63539, I63541, I63542, I63549, I6359, I636, I638, I639, or I6789, not POA

Low

Surgical re-exploration

This measure only applies to encounters in the CABG cohort

Encounter has any non-CABG procedure codes (with an HCUP Procedure Class of 3 or 4) on or after the date of principal procedure

Low

Postoperative renal failure

Encounter has a diagnosis code of E883, I120, I129, I1311, N170, N171, N172, N178, N179, N181, N182, N183, N184, N185, N186, N189, N19, R34, or T795xxA, not POA

Low

Prolonged Intubation

Encounter has a procedure code of 5A1945Z (Respiratory Ventilation 24-96 Consecutive Hours) or 5A1955Z (Respiratory Ventilation, Greater than 96 Consecutive Hours)

Low

Reaction to Anesthesia or Drug Induced Delirium

Encounter has a diagnosis code of T8859 (Other Complications of Anesthesia), not POA

Low

Medical Pulmonary Embolism/Deep Vein Thrombosis

Encounter has a medical MDC and a diagnosis code of I2602, I2609, I2692, I2699, I82401, I82402, I82403, I82409, I82411, I82412, I82413, I82419, I82421, I82422, I82423, I82429, I82431, I82432, I82433, I82439, I82441, I82442, I82443, I82449, I82491, I82492, I82493, I82499, I824Y1, I824Y2, I824Y3, I824Y9, I824Z1, I824Z2, I824Z3, or I824Z9, not POA

This measure extends beyond HAC 10 (DVT/PE with Total Knee or Hip Replacement), which only targets THA/TKA patients, and PSI 12 (Perioperative PE/DVT Rate), which only targets surgical patients.

Low

Eclampsia, postpartum

Encounter has a diagnosis code of O152, not POA

Low

Major Puerperal Infection, Postpartum

Encounter has a diagnosis code of O85 or O8669, not POA

Low

Failed Forceps Delivery

Encounter has a diagnosis code of O665, not POA

Low